Security Flex 125 Program Enrollment Booklet

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1 SM Security Flex 125 Program Enrollment Booklet Save on Your Out-of-Pocket Medical and Dependent Care Expenses Save Money on FICA and Income Tax Handy Flex Card for Easy Payments Instant Access to 100% of Medical Account Value

2 Health Care Reform Changes affecting Security Flex 125 plan Over-the-counter medicines require a doctor s prescription. Effective January 1, 2011 no over-the-counter medicines, other than insulin, are eligible for reimbursement without a prescription. Examples of items that will require a prescription are: pain medication, cold medication and allergy medication. Over-the-counter items that are not medicine are still eligible for reimbursement without a prescription. Examples of items that are still eligible without a prescription are: Bandages, ace wraps, crutches and contact lens solution. Over-the-counter items that require a prescription are not able to be purchased with the flex debit card. These items will require a manual claim to be submitted. Limitation on Salary Reductions Beginning January 1, 2013 Health care reform imposes a $2,500 limit on annual salary reduction contributions to medical reimbursement FSAs effective for taxable years beginning January 1, The $2,500 limit is a calendar-year limit that applies to all plans. The limit is a flat dollar amount and applies on a perparticipant basis. The $2,500 amount is indexed for inflation for taxable years after December 31, Table of Contents Can You Use More Spendable Income? Qualifying expenses Submitting Claims Security Benefit s Flex Convenience Card Security Flex 125 Reimbursement Claim Form...14 Security Flex 125 Employee Benefit New Year Enrollment Form Employee Benefit Worksheet Advantages To You: 1. Save money on taxes by contributing to your account with pre-tax dollars. 2. Security Benefit funds 100% of your medical expense account from day one, so you don t have to wait for the benefits of participating. 3. Avoid the hassle of paperwork by using the handy Flex Card to pay for eligible medical expenses like prescriptions or co-pays. Participants in the Security Flex 125 Flexible Benefits plan can experience the following tax savings by funding their medical and dependent care expenses with pre-tax dollars: 1 Federal Income Tax (Filing jointly, taxable income not over $61,300) 15.00% + Social Security 7.65% + Estimate of State Tax Savings % Total Savings 27.65% 1 FICA withholding may vary by state and employer. State income tax savings vary by state and are not applicable in states without income tax and in PA and NJ. 2 Based on estimated rates. Please see page 11 for important information regarding the Security Benefit Flex 125 convenience card. 1 SECURITY FLEX 125 PROGRAM

3 CAN YOU USE MORE SPENDABLE INCOME? Why Pay Taxes That You Don t Have to Pay The Security Flex 125 Program offered through your employer allows you to pay less in taxes and take home more of your hard earned income. Here s how it works. Section 125 of the Internal Revenue Code allows employers to set up Flexible Spending Accounts for medical and child care expenses as part of their cafeteria plans. As an employee, you can set aside part of your income on a pre-tax basis for medical and/or child care expenses that you will incur over the course of the year. Then, after you pay for child care or eligible medical expenses, you simply submit the bill or receipt with the proper form and you will be reimbursed for your expenses from the Flexible Spending Account. Here s how the Security Flex 125 Program can help increase your spendable income: Employee Savings With Medical Care Services Without With 125 Plan 125 Plan Gross Pay $36, $36, Medical and Dental Plan Premiums Non-reimbursed Medical Expenses Total Taxable Income (for Federal Purposes) $36, $34, Deductions From Pay* Federal Withholding $ 5, $ 5, State Withholding 1, , FICA and Medicare Tax 2, , Medical and Dental Plan Premiums Total Income Deductions $ 9, $ 8, Take Home Pay Total Taxable Income $36, $34, Non-reimbursed Medical Expenses Income Deductions 9, , After-Tax Take Home Compensation $25, $25, *Federal, State and FICA tax vary from state to state. By using the Flexible Spending Account for medical expenses, you could have an increase in your spendable income of almost $25 per month. That s an annual increase of almost $300. SECURITY FLEX 125 PROGRAM 2

4 Employee Savings With Dependent Care Services Without With 125 Plan 125 Plan Gross Pay $36, $36, Non-reimbursed Dependent Care Expenses , Total Taxable Income (for Federal Purposes) $36, $31, Tax Deductions From Pay* Federal Withholding $ 5, $ 4, State Withholding 1, , FICA and Medicare Tax 2, , Medical and Dental Plan Premiums Total Income Deductions $ 9, $ 8, Take Home Pay Total Taxable Income $36, $31, Non-reimbursed Medical Expenses 4, Income Deductions 9, , After-Tax Take Home Compensation $22, $23, *Federal, State and FICA tax vary from state to state. By using the Flexible Spending Account for child care expenses, you could have an increase of over $90 per month in your spendable income. That s an annual increase of almost $1,100. While most medical and child care expenses are eligible for reimbursement, some restrictions do apply. Read the Security Flex 125 booklet carefully before enrolling in the plan. You must be enrolled by your employer s deadline to participate in the program, so contact your employee benefits personnel today to learn more about how you can benefit from the Security Flex 125 Program! 3 SECURITY FLEX 125 PROGRAM

5 What Qualifies Medical Expenses* The medical reimbursement account will set aside part of your income on a pre-tax basis for medical expenses that you will incur during the coverage period. The coverage period is the effective date of the plan or the date the employee enrolls in the plan through the plan year or grace period end date. Expenses are incurred when the service is provided and not when the employee is formally billed, charged for, or pays for the medical care. Medical expenses include payments you make for the diagnosis, treatment or prevention of disease or for the treatment affecting any part or function of the body. Samples of these expenses would include charges and co-pays for medical appointments, Lasik eye surgery and prescription medications. Cosmetic procedures are not eligible for reimbursement. Any expenses reimbursed through your account cannot be claimed for income tax purposes. The following is a partial listing of medical expenses which are allowed and disallowed through your FSA. Please refer to IRC Section 213(d) for a complete listing of allowed expenses. You are also able to find additional details on eligible expenses on our website under the Forms section. ALLOWED MEDICAL EXPENSES Acupuncture Ambulance Chiropractor fees Coinsurance (co-pays and deductibles for health, dental and vision) Corrective eye surgery Crutches (purchase or rental) Hearing aids and hearing aid batteries Hospital services Immunizations Insulin and equipment needed to inject the insulin Laboratory fees Medicines (prescriptions) Organ donation/transplantation Orthodontic fees Over the counter medicines (with prescription) Prescription eyeglasses, sunglasses, Contact Lenses and solutions associated with their care Physical, Dental and Eye exams Reading glasses Surgery/operations Weight-loss program and/or drugs to induce weight loss when prescribed for a specific diagnosis Well-child care Wheelchair X-ray fees DISALLOWED MEDICAL EXPENSES Chapped lip treatments Cosmetic surgery (expenses exceptions if medically necessary) Dancing lessons, swimming lessons, etc., even if recommended for the general improvement of your health Electrolysis or hair removal Face creams, moisturizers, suntan lotions Funeral Expenses Hair transplant (i.e. Rogaine, Propecia) Insurance premiums for individual and/or spouses health, dental, and/or policies covering loss of earnings, loss of a limb or eyesight Maternity clothes Medicated shampoos and soaps (unless prescribed by a doctor) Teeth Bleaching Toiletries Toothbrushes, toothpaste Vitamins and supplements for maintaining general good health ALLOWED OVER-THE-COUNTER MEDICATIONS Reimbursable: Bandaids, bandages, gauze pads, first aid kits Cold/hot packs for injuries, crutches Contact lens solution, cleaners Carpal tunnel wrist supports Condoms, spermicidal foam Insulin Nasal strips for snoring Orthopedic shoe inserts Pregnancy test kits Reading glasses Thermometers (ear or mouth) *It is possible that changes in the IRS rules can affect the Allowed and/or Disallowed Expenses categories. SECURITY FLEX 125 PROGRAM 4

6 Dependent/Day Care Expenses* The dependent care account will set aside part of your income on a pre-tax basis for child/dependent care expenses that you incur during the coverage period. The coverage period is the effective date of the plan or the date the employee enrolls in the plan through the plan year or grace period end date. Expenses are incurred when the service is provided and not when the employee is formally billed, charged for, or pays for the dependent care. Expenses include payments made for the care of a child under 13 and/or a dependent regardless of age who requires care due to an inability to care for him or herself, to enable you (and, if married, your spouse) to remain gainfully employed. For dependents to be eligible, they must spend at least eight hours a day in your home. You must declare them as dependents (or have the ability to declare them as dependents except for their level of gross income) on your Federal tax return. Reimbursement for amounts cannot be claimed if paid to your spouse or tax dependent. Any expenses reimbursed through your account cannot be claimed for income tax purposes. Reimbursements can only be received up to the amount deposited for your payroll deductions. The following is a partial listing of dependent care expenses which are allowed and disallowed through your FSA. You are also able to find additional details on eligible expenses on our website under the Forms section. Please remember day care expenses must be incurred to be eligible for reimbursement. ALLOWED DEPENDENT/ DAY CARE EXPENSES Licensed day care facility Preschool program In-home child and dependent care services Day camp expenses Elder care Any other qualified dependent care expenses as defined by the IRS DISALLOWED DEPENDENT/ DAY CARE EXPENSES Overnight camp Services solely for the purpose of household cleaning Day care for children past their 13th birthday *It is possible that changes in the IRS rules can affect the Allowed and/or Disallowed Expenses categories. 5 SECURITY FLEX 125 PROGRAM

7 Submitting Claims You may send in claims throughout the year. Only claims for services incurred during the coverage period are eligible for reimbursement. The coverage period is the effective date of the plan or the date the employee enrolls in the plan through the plan year or grace period end date. Expenses are incurred when the service is provided and not when the employee is formally billed, charged for, or pays for the services. Expenses must be incurred before reimbursement can be made. For example, if you prepay your day care provider at the first of the month or if you are required to pay for dental expenses prior to the services being provided, you cannot submit a claim for those expenses until the services have been received. IRS regulations specifically mandate, A flexible spending account cannot make advance reimbursement of future or projected expenses. It is important that you plan your deposits carefully. Please remember that unused amounts may not be carried forward in the next plan year. In accordance with Internal Revenue Service guidelines, money remaining in the plan at the end of the plan year will be forfeited if a claim for reimbursement is not submitted by the end of the run-out period. The run-out period is the 90 day period following the end of the plan year or grace period, if applicable. A claim form must be completed and signed when submitted a flexible spending claim. You must attach legible copies of itemized receipts, statements, or an explanation of benefits from your insurance provider. An itemized receipt must include The provider name and address Date of service For whom the service was provided Charges for the service Service(s) that were provided SECURITY FLEX 125 PROGRAM 6

8 Submitting Claims (continued) Common reasons claims may be denied or delayed Statements showing balance due or received on account Claim forms received without a signature Services not incurred during the coverage period The claim form provides a space for you to itemize your claim. This is useful when you have multiple items with varying amounts. The worksheet allows you to review your claims and ensure that they contain all the required information. Medical reimbursement claims are processed within three to five business days after they are received in good order. You should receive reimbursement of your claims within seven to ten business days. Dependent care reimbursement can only be paid up to the amount of deposits received in your account. If a claim is received for more than your deposits the claim will be placed on-hold waiting on additional deposits to be received. You will need the provider s name and address, social security number or tax identification number for your records. Dependent care claims are processed within one to three business days after they are received in good order. You should receive reimbursement of your claims within five to seven business days. Please note: All claims received will be retained at Security Benefit and will not be returned once received. Example John River pays his day care provider on March 1 for March day care. He immediately sends in his claim for reimbursement. Why doesn t he receive his reimbursement until the end of the month? Answer The IRS has indicated that expenses are not reimbursable until the expense has been incurred. Day care expenses claimed are for the time you and your spouse go to work. Therefore, expenses will not be incurred until the end of March. Your claim will be held until the end of the month before being processed. You should check with your employer to determine when the dependent care deposits will be sent to Security Benefit. According to IRS regulations, dependent care reimbursements cannot be made until Security Benefit has received the employer s deposit. Therefore, your claim could be received, processed and pended until the employer s deposit is received. Once that deposit and your claim have been received, a payment will be mailed to you or an automatic deposit will be directed to your bank. 7 SECURITY FLEX 125 PROGRAM

9 Reasons Why Claims May Not Be Reimbursed All claims received will be processed. However, only those claims that are eligible for reimbursement according to IRS regulations will be reimbursed. Claims received that are not eligible for reimbursement will be kept in your Security Benefit file. You will receive a letter indicating the reason that the claim is ineligible for payment. If you have some claims that are reimbursable and some that are not, you will receive a statement. The statement of benefits will list the reasons why ineligible claims could not be paid. Many scenarios exist that may prevent or delay processing of a claim. The most frequent reasons are listed below. The boldfaced portion will appear on your statement as listed below. Please refer to this list to troubleshoot your claim. Reasons Cosmetic expense ineligible Per IRS regulations cosmetic procedures do not qualify. This includes cosmetic surgery or other procedures that are for improving the patient s appearance and don t meaningfully promote the proper function of the body or prevent or treat illness /disease. Covered by insurance Explanation of Benefit shows the insurance provider paid the expense. Date of Service in the future Reimbursement for future expenses are not eligible for reimbursement. Duplicate receipt The expense has been received for reimbursement previously. Expense incurred outside of plan dates The expenses submitted were not within your plan year. Only expenses incurred within the plan year, prior to your last date of employment, are eligible for reimbursement. Expense incurred prior to employment or after termination of employment Expenses incurred prior to your employment or after termination date are not eligible for reimbursement. Ineligible Expense Expense not eligible according to IRS requirements. Insufficient funds You have received reimbursement for your maximum election for the current plan year; therefore, no further reimbursement is available. Insurance premium ineligible Insurance premiums are not a qualifying expenses. Itemized receipt required Please submit an itemized statement for the claim. Itemized statements should include: provider name and address, date of service, patient name, unreimbursed charges for the services, services provided or an EOB from your insurance company. Maximum contribution paid out You have received reimbursement for your maximum election for the current plan year; therefore, no further reimbursement is available. SECURITY FLEX 125 PROGRAM 8

10 Reasons (continued) No Claim Form Received Please submit a signed claim form with your itemized receipt. Offset ineligible transaction The reimbursement request was used to offset an overpayment on the account. Over-the-counter needs prescription As of January 1, 2011 IRS requires all over-thecounter medications to have a prescription. Plan year deadline expired Claims incurred during your plan year must be submitted no later than 90 days after the plan year ends. We received your claim after this time as a result no payment is available. Receipt unreadable The documentation that was received was not a readable copy. Received on account ineligible Documentation received shows balance due or amount paid. Itemized statements should include: provider name and address, date of service, patient name, unreimbursed charges for the services, services provided or an EOB from your insurance company. Signature required All forms must be signed by the participant. You will have 180 days following receipt of this notification in which to appeal the decision. Appeals should be directed to: Benefit Claims Administration ERISA Appeals Administrator PO Box Topeka KS You may submit written comments, documents, records and other information relating to the claim. If you request, you will be provided reasonable access to and copies of all documents, records and other information relevant to the claim free of charge. Upon receipt of additional information related to the claim, we will review the claim and provide a written response to the appeal within 60 days. (This period may be extended an additional 60 days under certain circumstances.) You also have the right to bring a civil action under section 502 of ERISA following denial of a claim. 9 SECURITY FLEX 125 PROGRAM

11 Service Options Web Access The 24-hour website for your Section 125 Flexible Spending Account is You will need to create an account for first-time login. To create your account you will need your Flex Convenience Card number or your Employer Identification Number. The employer identification number can be found on your welcome letter. Fax Access For 24-hour toll-free fax access for flex reimbursement, call: Phone Access For personalized telephone support, call toll free, Monday-Friday from 8:00 am to 5:00 pm Central Time. Paperless Communication You can receive paperless communication regarding your flexible spending account by providing your address. Please login to the website and update your address or and request your address be added to your account. Providing your address will allow you to receive quarterly balance summaries, year-end reminders, communications on your claims once they are processed. If your address is not on file you will not receive quarterly balance statements. You will receive one reminder at year end via mail. SECURITY FLEX 125 PROGRAM 10

12 Important Information Regarding the Flex Convenience Card (Mbi Benefits Card ) Purchases made with the Flex Convenience card (Mbi Benefits Card ) may still require proof of charges and claims. Below are some guidelines your must follow when making purchases with your card. IRS regulations require that you keep copies of receipts and invoices on all purchases made with your card or any other submitted claims within your Flex Spending Account. Security Benefit may also request a copy of your receipt and invoices for charges paid through your Flex Convenience card. Your receipt and/or invoices must show: o Name of provider o Date of purchase o The item or services purchased o Your cost o Name of person for whom the purchase was made (i.e. child s doctor appointment, spouse s prescriptions, etc.) If you receive a letter or notification requesting more information/documentation and do not respond, your Flex Card will be turned off. You will typically have 10 days to respond after the date of the notice. If you have a recurring expense that is an odd dollar amount or over $ Please call: and we will enable your card to accept the recurring expense. (e.g. orthodontia, prescriptions, etc.) The Flex Convenience card may not be accepted in all locations. Please check with your pharmacy or drug store before placing your order. As of July 2009, the IRS requires all Drug Stores and Pharmacies to have their UPC Codes on the standardized System. This means some of the smaller stores may no longer accept the Flex Cards if they have not updated their system. If you accidentally use the card for ineligible expenses you will be required to send a check or money order to refund the charge back to the plan. If the refund is not received we will request your employer withhold the amount from your pay on an after-tax basis. If you need further assistance with a claim/card reimbursement please contact us at SECURITY FLEX 125 PROGRAM

13 Security Benefit s Flex Convenience Card (Mbi Benefits Card ) FAQ What is the Mbi Benefits Card? The Mbi Benefits Card is a debit card that can simplify the process of paying for eligible expenses. It is an alternative to the traditional method of filing claims. You can use the card at qualifying merchant locations wherever MasterCard is accepted from physician and dental offices to pharmacies and vision service locations. Exactly what is the convenience of the card? The card allows you to pay for eligible expenses at the point of service. The convenience is: Immediate access to FSA account you avoid paying with cash or check Immediate payment of the expense you avoid waiting for a reimbursement check Claim form for documentation provided to you by mail or The ease of use at the point of sale and the reduced burden of having to pay money out-of-pocket, completing a claim form and waiting for a reimbursement has proven to be extremely convenient for plan participants. How does the Mbi Benefits Card work? The Mbi Benefits Card is accepted only at certain merchants. This includes physician offices, hospitals, dental offices, pharmacies (including mail order), hearing/vision care provides, etc. As you incur health care expenses, you present your card for payment. The card system will validate that your coverage is active and that you have available funds to cover the transaction. You must retain documentation of the expense, as you may be required to substantiate transactions in some cases by providing copies of the documentation. We recommend that you keep all documentation in a separate envelope for the entire plan year in the event the information is requested. For example, itemized receipts listing the merchant name, name of the item/product, date and amount will be requested for all over-the-counter purchases. Use the card only for qualifying expenses, otherwise, you ll have to write a check back to the plan or the card will be deactivated. The card works great for prescription drug or office visit co-pays. If you purchase a prescription drug along with non-qualifying items, be sure to ask the merchant to ring up the prescription separately so that you can use the card. You can use the card for other health expenses, including medical, dental, vision and hearing. The card is valid for a three-year period and will contain information regarding your current plan year election. Each year when you re-enroll, the card will reflect that plan year election amount(s). Is this process paperless? No. Although there is no requirement for you to complete conventional claim forms, additional documentation will be required in order to meet IRS guidelines. Therefore, you must keep copies of all receipts and itemized statements (not the credit card receipt) for each purchase for the entire plan year. You ll receive a letter, or , requesting the documentation and you will be required to submit this information to substantiate the expense according to IRS regulations. You will need to return the signed letter, or , along with the documentation. DO NOT SEND IN THE REQUESTED INFORMATION ON A REGULAR CLAIM FORM. In some cases, you will not need to send in documentation. This occurs when your expense matches a copay that is preset to match copays that may apply to your employer s health insurance. What type of additional documentation is required? The documentation is the same information required for traditional paper claim forms. You must keep copies of all transaction receipts for each card purchase so that these can be provided to the administrator upon request. This includes itemized cash register receipts that list the merchant name, name of the item/product, date and amount (for items such as hearing aid batteries, contact lens solutions or over-the-counter medicines/drugs), insurance plan Explanation of Benefit (EOB) statements, and itemized statements (for vision or other health care expenses). (It does not include the credit card receipt.) For prescription drugs purchased at a pharmacy, this would include the pharmacy receipt (or you can request a printout from your pharmacy). Whenever possible, however, you should purchase prescriptions through any available mail-order service as this not only reduces your costs, it can also help reduce or even eliminate the documentation requirements! We recommend you keep all documentation in a separate envelope at home or work for the entire plan year. REMEMBER, THIS DOCUMENTATION NEEDS TO BE RETURNED ALONG WITH THE SIGNED LETTER, OR . SECURITY FLEX 125 PROGRAM 12

14 Security Benefit s Flex Convenience Card (Mbi Benefits Card ) FAQ What happens if I forget to reply to the letter requesting additional documentation? In the event the request for additional information is ignored, a second letter is generated giving you additional time to respond. If there is no reply to the second request, collection procedures will begin. The card will be deactivated and you will be required to make reimbursement to the plan by personal check. What happens if I accidentally use the card for ineligible or non-qualifying expenses? Be sure to have merchants ring up your qualifying expenses separately from your other personal items so you can use the card. In the event the card is misused, you will be required to write a personal check back to the plan. If you do not reimburse the plan, the card will be deactivated and collection procedures will begin. In addition, your employer will be contacted. Are there any limitations on the usage of the card? Aside from the specific merchant codes and the plan year election amount, there are no limitations. There are no transaction fees, and you have unlimited use of the card. Remember, though, that you must use the card for qualifying items only! Will I receive a cardholder agreement? Yes, you will receive a Fund Transfer Disclosure Statement (cardholder agreement) that you should carefully read and must abide by. You must also read the back of your convenience card, and sign it. By using the card, you agree to the provisions of the cardholder agreement. That is, you agree to use the card only for qualifying expenses, and to provide documentation upon request. Must I use the card for all expenses I incur? No. During the plan year, you can file traditional paper claims or use the Mbi Benefits Card. Remember, the card is valid for a three-year period, so if you choose not to use it at all, we recommend you keep the card in a safe and secure place in the event you wish to use it in future years. Will I receive a statement or an accounting of my Mbi Benefits Card transactions? All transactions, whether they are paper claims or card transactions, will be reflected on your periodic statements provided by Security Benefit. You can also access our web site at How do I report a lost or stolen card? Lost or stolen cards must be reported as soon as possible. During our normal hours of operation, contact us at Before or after business hours and weekends, lost or stolen cards may be reported at There is a $10.00 fee for card replacement for any reason. Can I order a card for my dependents? Yes. You can order an extra convenience card for your spouse or college student by completing the application provided. Please be certain that your dependent fully understands how to appropriately use the card for qualifying expenses only, and that they retain copies of documentation of each transaction. There is a one-time cost of $5.00 for one additional card. What happens if I have a $1,000 limit on my Mbi Benefits Card, but I have a $1,500 transaction? Transactions exceeding your card limit or available balance will be rejected. For this reason, as you use the convenience card throughout the year, you should check your available balance at www. securitybenefit.com. This way you will know how much is available and you can request that the merchant charge only up to the available balance on the card. You may pay for the transaction and file a claim. Your reimbursement would only be for the amount of money you elected, minus the card fee and any other expenses incurred previously. You would not be able to get more reimbursements during the plan year either using the card or by claim forms as you would exceed your election amount. If I terminate employment, can I continue to use the Mbi Benefits Card? No. The card is inactivated at that time. If you have qualifying expenses to submit after your termination of employment, you can use the traditional method of filing a claim form with appropriate documentation. Claim forms are available on the web site. (Remember, though, that your qualifying expenses must be incurred during your period of coverage.) 13 SECURITY FLEX 125 PROGRAM

15 Questions? Call our National Service Center at Security Flex 125 Program Medical/Dependent Care Reimbursement Program Claim Form Instructions Use this form to request medical expense or dependent care reimbursement. Please type or print. 1. Complete all sections of the form and attach legible copies of itemized statements or an Explanation of Benefits from your insurance provider. 2. You must sign Section 2 of this form. If the form is not signed, your claim will not be processed. 3. Claims may be submitted by fax, or postal mail. Please retain a copy for your records. 4. Claims must be submitted in good order prior to the run-out date in your plan. 5. Do not use this claim form for Flex Convenience Card transactions or a claim that was submitted online. 1. Provide Personal Information Employer Name Social Security Number Daytime Phone Name of Employee First MI Last Mailing Address Street Address City State ZIP Code Check if address change Address By providing an address you consent to receive electronic communications regarding your Flexible Spending Account via . You are able to update your address at or by contacting Security Benefit by phone, , or postal mail. 2. Provide Signature I agree: That this claim represents qualifying medical or dependent care expenses not covered/reimbursed by insurance. My signature below confirms my understanding and agreement with this requirement. I further understand that any claim that does not meet these requirements may result in this payment being considered a taxable payment by the IRS. I understand that the direct deposit arrangement will continue until Security Benefit receives written notification from me stating otherwise. This is to certify that I have incurred expenses that qualify for reimbursement under my employer s Security Benefit Medical/Dependent Care Reimbursement Program. None of these expenses have previously been submitted. I certify that these expenses will not be paid or reimbursed by any insurance company or from any other source or I may be subject to IRS fines and/or penalties of perjury. I hereby request reimbursement for these expenses to the extent allowable. I understand that at the end of the plan year all unpaid claims (even if less than $25.00) will be reimbursed in full and that any remaining fund balances at the end of the plan year will be forfeited to my employer. By providing an address, I consent to receive all communications regarding this plan via . x Signature of Employee Date (mm/dd/yyyy) Please Continue /02/12 (1/2)

16 3. Provide Summary of Itemized Bills Dependent Care Expenses (DCA) Provider Name Dependent Name Age Date of Service Requested Amount See IRC Section 129 for qualifying DCA expenses. Total DCA Request Unreimbursed Medical Expenses (FMR/FSA) Provider Name Patient Name Description of Service Date of Service Requested Amount See IRC Section 213 for qualifying FMR/FSA expenses. Total FMR/FSA Request 4. Reimbursement Method Request reimbursement by direct deposit Request reimbursement by check Please provide your bank information below if you wish to have payments from Security Benefit made by direct deposit to your bank account. If any information is missing your request may be delayed. You may also attach a void check to ensure necessary information is provided. Receipt by said bank of such credit entries shall be deemed receipt by you. Bank Account Type (please check one): Checking Savings Bank Name Name on Bank Account Bank Routing Number Bank Account Number (Do not include the check number) DO NOT INCLUDE CHECK NUMBER Routing Number Account Number Date 0001 $ Dollars For additional information on eligible expenses you may also review the Qualified Expense Chart available on our website under the Forms section. Mail to: Security Benefit PO Box Topeka, KS or Fax to: Visit us online at ebdept@securitybenefit.com /02/12 (2/2)

17 Employee Benefit Election Form for New Plan Year Enrollment Questions? Call our National Service Center at Instructions Use this form to add or make changes to your employee benefit elections. Please type or print. 1. Complete all sections of the form. 2. Return completed form to your representative or benefits administrator. 1. Provide General Information Name of Employer Plan year to (mm/dd/yyyy) (mm/dd/yyyy) Name of Employee First MI Last Social Security Number Date of Birth Gender Male Female (mm/dd/yyyy) Mailing Address Street Address City State ZIP Code Address Daytime Phone By providing an address you consent to receive electronic communications regarding your Flexible Spending Account via . Date of Hire Work Location (mm/dd/yyyy) Do you have a scheduled termination date? Yes No 2. Provide New Election Information Date (mm/dd/yyyy) Amount per Payroll Number of Pays Annual Election Medical Reimbursement (FMR/FSA) x = Dependent Care Reimbursement (DCA) x = TOTAL REDUCTIONS I decline participation in IRC Sec Flex Convenience Card Authorization The Flex Convenience Card is not a credit card but a debit card electronically linked to a participant s Flexible Spending Account balance. Participants may use the Flex Convenience Card for eligible health care related expenses. The Flex Convenience Card will be automatically issued to you when you enroll in the Medical FSA. If you would like to request a dependent card please complete the information below. YES, I want a spouse/dependent card (Limit one) Name Social Security Number First Last Please Continue /02/12 (1/2) SECURITY FLEX 125 PROGRAM 14

18 4. Provide Signature I understand, acknowledge and certify: No changes in the Security Benefit elections will be allowed in the plan year unless a family status change has occurred. The election change must be made with my benefit administrator within 30 days of the status change. Any benefit change requested due to family status must be necessary and appropriate as a result of the family status change. I understand that I am responsible for providing substantiation for all Flex Convenience card transactions. I will refund back to my account any amount associated with a transaction that is deemed ineligible. I also am responsible for any spouse/dependent card transactions. I understand there may be a charge for the Flex Convenience card by my employer. I hereby acknowledge that I have received a summary of the material terms of the plan and authorize deduction from my salary for the above salary deduction amount. I hereby authorize my employer to reduce my salary by the above salary deduction amount to purchase employee fringe benefits under IRC Sec I understand that I may not change this deduction amount during the plan year except for the circumstances defined in IRC Sec. 125 regulations (definitive information in enrollment package). x Signature of Employee Date (mm/dd/yyyy) Mail to: Security Benefit Life Insurance Company PO Box Topeka, KS or Fax to: to: ebdept@securitybenefit.com /02/12 (2/2)

19 EMPLOYEE BENEFIT WORKSHEET Planning to save is easy! This simple worksheet helps you estimate your expenses for the plan year. Estimated Dependent Care Expenses: Dependent care required for you and your spouse to continue working. Total Estimated Dependent Care Expenses for this plan year: $ Estimated Out of Pocket Medical Expenses (for you, your spouse and any tax dependents): Medical Insurance Premiums of any kind are not covered Medical Co-pays: Coinsurance Prescription Drugs Over-the-counter Medication (see eligible expenses) Dental Coinsurance Orthodontia Non-covered (major services) Hearing Coinsurance/Exams Hearing Aid Vision Coinsurance/Exams Glasses Contact Lenses Corrective Eye Surgery Other Miscellaneous Total Estimated Medical Expenses for this plan year: $ SECURITY FLEX 125 PROGRAM 18

20 Rules For IRC SEC. 125 Flexible Benefit Plans The Security Flex 125 Program qualifies under Section 125 of the Internal Revenue Code, which allows employers to set up Flexible Spending Accounts (FSA) for dependent care and/or medical expenses as part of their cafeteria plans. These expenses can be paid with before-tax dollars. Below are the rules that the plan must adhere to: Plan Year Rules During the plan year, you are only allowed to make changes in the benefits selected if there is a family status change. (For example marriage, divorce, birth, death, etc.) All dollars set aside in an FSA plan must be used during the plan year. Any dollars not spent by the end of the plan year must be forfeited. Only charges for services provided or expenses incurred during the coverage period year are eligible for reimbursement. Amounts paid under the plan are not eligible as tax deductions on your Federal Income Tax Return. Maximum Contributions The maximum allocation to your Medical Reimbursement account may not exceed the annual plan maximum determined by your employer. The maximum dependent care expense allowed is $5,000 per calendar year per household ($2,500 in the case of a separate return filed by a married person). Eligible Expenses Expenses for you, your spouse and any taxable dependents are eligible. The Dependent Care FSA allows expenses for: (a) your dependent under age 13 for whom you may claim an exemption deduction, or (b) your dependent who is physically or mentally not able to care for himself or herself and who relies on you for the majority of his or her support, or (c) your spouse who is physically or mentally not able to care for himself or herself. Examples of Eligible Medical Expenses Medical expenses not paid by your health insurance including (but not limited to): Co-pays and deductibles for health, dental and vision Prescriptions Orthodontia Prescription eyewear including: eyeglasses, sunglasses, contacts and solutions associated with their care. Under the IRC Sec. 125 Flexible Benefit plan, you designate the amount of dollars that you plan to use at the beginning of the plan year. These dollars are applied to the appropriate account (Medical or Dependent Care) each month. You may submit claims for payment (subject to a minimum reimbursement of $25). You may submit with each claim as many bills or receipts as you have accumulated. Qualifying medical expenses will be reimbursed up to your annual election upon receipt of proper documentation, regardless of your account balance. Dependent Care expenses are reimbursed as funds are available in the account. Your reimbursement may not exceed your account balance /02/12